Background: Assessing severity of illness using available electronic medical record (EMR) data on admission and predicting inpatient mortality is very challenging. Lacking standardized practices around end of life issues, hospitalists use their clinical judgment in making these crucial decisions. Prolonged discussions may be needed in medically complex patients to direct an optimal plan of care [...]

Background: Capturing appropriate clinical documentation allows providers to best approach treating patients and can also be utilized for quality monitoring of outcomes within health systems. Mortality measures are used by the Centers for Medicare and Medicaid Services (CMS) for reimbursement and payment. (1) Observed mortality includes all deaths which occur in the hospital during a [...]

Background: Accurate clinical documentation is essential for capturing patient severity of illness (SOI) and risk of mortality (ROM). These metrics directly influence hospital quality reporting, including rankings like Vizient and metrics such as Observed-to-Expected Mortality (O:E) ratios. Traditional documentation methods rely heavily on manual input, which in busy clinical practices, results in underrepresented patient risk [...]